Tricare Philippines Newsletter
Current Understanding of the Provider
The TRICARE Management Activity (TMA) added the Philippine unique
requirement that claims would only
be paid for care provided by certified providers.
The stated purpose for this requirement was to insure that only care
provided by licensed and properly trained providers would be considered
when processing claims. This process was implemented in reaction to
some military retirees and local providers submitting claims for care
In reality, for many beneficiaries it means care provided by legitimate
licensed and trained providers is also denied. Not because the care is
unnecessary or the provider is not a legitimate licensed provider but
because a “process” was not completed. There are other approaches that
TMA could have used to accomplish the same end and at lower cost but
they contracted with a U.S.
company, International SOS (ISOS) to develop the process for them.
Under TRICARE Standard, TRICARE For Life functions as Standard
overseas, the major advantage as advertised by TMA is freedom of choice
to chose providers of your choice and this option is available to
every other beneficiary overseas and in the states; only in the
Philippines is this restriction applied to Standard.
TMA refuses to explain the process except to say it is proprietary and
therefore confidential and cannot be discussed with beneficiaries in
spite of multiple written and verbal inquiries. Even the reason for a
provider denial is considered proprietary and will not generally be
released. However we have gathered major portions of the process
through discussions with current and former ISOS employees, and by
using our group of retirees to question their providers, both those
certified and those reported as not certified, to develop, what we feel
is a fairly accurate picture of the actual process.
Why should we know how it
It is important to understand the process in order to understand what
happens that causes thousands of claims to be denied for legitimate
care provided by trained, licensed and qualified providers. With this
understanding we are then better able to overcome or circumvent these
denials in order to get these legitimate claims paid.
So what is the process?
A beneficiary sees a local provider that is not certified and submits a
claim. When Wisconsin’s
Physician Service (WPS) receives the claim they check the providers
against the certified provider list. If the provider is not certified
they notify ISOS and request a certification. WPS will then hold
the claim for 90 days while ISOS completes the certification.[i]
When ISOS completes the certification they notify WPS who then proceeds
with processing the claim. In the event that ISOS denies certification
or the 90 days expires without feedback from ISOS, WPS will deny the
claim using one of two reason codes, 018 PROVIDER NOT TRICARE
AUTHORIZED FOR THIS SERVICE or 135 PROVIDER IS NOT TRICARE AUTHORIZED
REQUESTED PROVIDER CERTIFICATION INFORMATION NOT RECEIVED. Why one code
or the other are used has never been explained to us.
The general process used by ISOS, as reported by physicians, other
providers and ISOS employees. First they check their files for the
provider. If they find that in the past the providers declined
certification they simply notify WPS that the provider is not certified
and close the case. Otherwise the process is to send the provider a
letter informing them that ISOS wants to certify them for TRICARE and
asks them to agree to that certification. An alternative method used sometimes
in the Manila area is to call the
provider and obtain this concurrence to certification. If the provider
declines to be certified ISOS annotates the file and notifies WPS. If
they agree to certification ISOS schedules a time to visit the provider
where they obtain copies of licenses, tax certificates and confirm that
the providers has a physical office at the location. (Because of a
recommendation by ISOS and concurrence by TMA physicians have to be
certified by physical location instead of being certified as an
individual so a single provider may have multiple certifications.) Once
this is complete and they are certified ISOS notifies WPS and the claim
process continues. If they are not certified ISOS also notifies WPS and
the claim is denied and returned for one of the reasons stated above.
That’s the official process however there are a number of issues we
have found surrounding this process that can cause claims to be denied.
Our members have
reported that ISOS has taken as long as seven months to actually
contact their provider and certify the provider.
- Providers decline
certification because they heard that there was a fee, are afraid
of being charged with fraud by TRICARE or they have no idea why
they are being certified.[ii]
- ISOS will not contact a
provider that previously declined certification but simply notify
WPS that the provider is not certified.
- Providers have told
beneficiaries that nobody contacted them from ISOS when the
beneficiary, whose claim was denied, questions the provider as to
why he declined certification.[iii]
- WPS denies a claim after 90+
days because ISOS has not responded but later ISOS notifies WPS
that the provider is certified but they take no action to reopen
the denied claim(s).[iv]
Wouldn’t it be better if we
could request certification before we see a provider?
This approach was recommended by us and approved by the Pacific area
office of TRICARE more than five years ago and was in place for
approximately one year until TMA in Washington discovered the new
process and stopped it claiming it was not required and unnecessary.
Inquires requesting reconsideration have been ignored.
What can we do to help insure a
provider is certified and we get paid?
When you see the provider
If the provider is a hospital, pharmacy or something similar see the
administrator or owner and explain that you and other US
military retirees and their families would like to use their facility
and explain that we have an insurance program known as TRICARE. Explain
that once you use any of their services and submit a claim that within
a few months, it is supposed to be within 90 days but we know ISOS has
taken as long as seven months, that a company, International SOS, out
of Manila will send them a letter asking if they want to be certified
and listing some requirements. Ask them to agree to this request and
see if they will agree and hopefully they will. Point out to them that
if they agree to certification, it does not obligate them to do any
additional requirements but it will allow you to get partial
reimbursement. Explain there is a little cost to them to copy a few
documents and some time to complete some forms. (If this is a physician
there may be significant additional expense if they have to register an
additional office with the Philippine BIR. ISOS requires each physical
office be registered which is not necessarily done by many physicians.)
Also tell them that by agreeing to certification he is not agreeing to
file claims. (I mention this because in the past ISOS staff has
insisted that a hospital being certified must submit claims and the
hospital involved refused certification because of it.) In the case of
a physician address this to him directly.
Try to determine if ISOS has ever asked them in the past to be
certified. They may not know the answer but it is best to ask since
ISOS will not even try to certify them if they have. If they declined
in the past you will have to convince the provider to call or mail ISOS
requesting to be certified. It may help if you agree to pay for the
call or the postage on the letter and even offer to prepare the letter
Then follow-up with the doctor or his staff after a few months to see
if ISOS has contracted them and also so they don’t forget why they are
If the provider you want certified is a hospital, the next time you have
to fill a prescription or need a lab test use the facilities at the
hospital and file a claim. This will get the process started. With a
hospital it is better to start the process with a small claim like a
prescription than an inpatient stay as the process can take months and
waiting for an inpatient claim will cause your money to be tied up
during that time. Also if the hospital is denied or declines
certification the loss will be much less.
When you submit the claim
Make sure you include the full name, address and specialty of the
provider with your claim. If the provider is certified at another
location include that information in your narrative as it may help
expedite the process by alerting ISOS to the previous certification as
they will already have many of the required documents from the previous
When your claim is denied for
If after all of this your claim is still denied for non-certification,
it is not over yet.
The first thing to do is look at the time between when WPS started
processing your claim and when it was denied.[vi] If the number of days are 15 or less the most likely reason
for denial is your provider had previously declined certification.[vii]
If this happens attempt to speak to the provider and explain that it
appears they previously declined certification and try to get them to
agree to send a letter requesting certification as addressed above. If
you are sure your provider will now agree to certification an
alternative approach is to follow the guidance on sending a request to
WPS as discussed below in the “If all else fails” section.
If the number of days between the start of claims processing and denial
exceed 15 days one of the following reasons is most likely.
- They were contacted but
declined to be certified.
- ISOS was not able to find the
physician, see End Noteiii
- ISOS still hasn’t gotten
around to contacting and certifying the provider.
The first steps
- Contact the provider and
verify that they were contacted by ISOS.
- If they were contacted confirm
they either a) declined certification or b) agreed to
If they agreed to certification but it has only been a week or so it is
likely the process had not completed but will in a few weeks. In that
case check the Certified Provider list at each update to determine
if the provider has been listed. Once the provider is listed, email WPS
and request the claim be reconsidered since the provider is now
certified. Alternatively resubmit the claim but indicate in the
narrative that the provider is now certified or the claim maybe denied
as a duplicate claim.
If they were contacted but declined to be certified there is little you
can do unless you can persuade the provider to change their mind. If
that happens then the actions addressed above in contacting ISOS must
If the provider wasn’t contacted you can wait and watch the Certified Provider list at each update to see if
they are finally certified. This can take a long time if ISOS has
delayed certification for whatever internal reason; our past experience
has shown that in some cases ISOS takes as long as seven months to get
around to doing a certification. While you are waiting also check back
with the provider from time to time to confirm if they were visited by
ISOS and to keep the certification process in their mind. Again once
the provider is listed, email WPS and request the claim be reconsidered
since the provider is now certified. Alternatively resubmit the claim
but indicate in the narrative that the provider is now certified or the
claim maybe denied as a duplicate claim.
If all else fails
If all else fails or if you don’t care to make the effort as addressed
above there is one more option.
The TRICARE Operations Manual, Chapter 24, Section 14 mentions how ISOS
is supposed to stack certifications for processing:
2.3.4 The TOP contractor shall use the following guidelines
for prioritizing certification of Philippine providers as follows:
126.96.36.199 Reviewing new providers.
188.8.131.52 Reviewing the TOP contractor's current certified provider
184.108.40.206 Reviewing non-certified providers on claims which have been
denied by the TOP contractor and the beneficiary/provider has
followed-up on why the claim was denied.
220.127.116.11 Reviewing non-certified providers on claims which have been
denied by the TOP contractor and the beneficiary/provider has NOT
followed-up on why the claim was denied.
While we have our doubts ISOS complies with the last paragraph,
18.104.22.168, the beneficiary can invoke the review outlined in paragraph
22.214.171.124 by inquiring as to the status of the provider’s certification
with WPS. Our information suggests that ISOS is supposed to relook
their previous action and in cases where they simply notified WPS that
the provider was not certified due to a previous declination, they will
re-contact the provider. But since TMA claims these processes are
proprietary and confidential we have not received an official
confirmation. When making this inquiry, be sure to make reference to
the claim number of the denied claim and quote the information above
and include a request that WPS respond with the results of this review.
These requests may be mailed, faxed or sent via the secure email
process via your WPS account.[viii]
Additional Information on
In some instances a physician maybe covered by a hospital’s
certification. For a physician to be paid under the hospital
certification they have to be on the paid staff of the hospital and
performing those duties which became part of your bill. In other words
they are paid by the hospital and do not bill separately. This can be
confusing in the Philippines because physicians routinely ask the
hospital to collect their fees at the same time they collect their
final payment and sometimes a physician might work privately and also
for the hospital at different times. But in general there are two
instances where the physician is covered by the hospital certification.
The first and most common are radiologists and pathologists who read,
interpret or certify these or other ancillary services. The second is
where a procedure is accomplished using a major piece of equipment
owned by the hospital where they either charge a single fee for the
service which includes physician fees[ix]
and in the eyes of WPS who, using U.S. medical billing standards, it
appears to be what they know as "global" billing or when the
bill itemizes the fees but only says "physician" or
"anesthesiologist" on the bill. Again WPS probably pays these
based on U.S.
medical billing standards and not necessarily on the reality of what is
really going on here.
We understand the two cryptic denial codes, listed above, provide no
usable information as to the real reason the provider was not certified
and therefore why your claim was denied. About 5 years ago we addressed
the need to add additional denial codes that specifically addressed the
certification status that resulted in the denial. The response from TMA
was the cost was prohibitive to add new codes. Recently we personally
addressed the issue again to a senior staff member of WPS who seems to
understand and agree with our concerns. However, feedback indicates he
is also getting the same response from TMA that it is cost prohibitive
but he is continuing to look into it. The troubling thing about the TMA
response is we know that over the last 5 years a number of new reason
codes have been added because, apparently TMA wanted them added, and
cost apparently wasn’t a factor. So we are not sure if we’re making
much progress on this front but will continue to pursue it.
The next newsletter will address issues with using the Certified
Provider list, including understanding how it is put together, issues
with the many data entry errors and how to overcome some of them and
alternative sources of information.
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[i] The current TRICARE
Operations Manual specifies 45 days but TMA finally realized that their
contractor was not completing certifications in that timeframe so
instructed WPS to hold claims for 90 days. This information was
obtained via email from a TMA employee.
[ii] Providers were
previously charged by ISOS for certification and charged for what they
were told was training to submit claims. This was prevalent in the past
but apparently not done today. However providers still shy away from
certification because of this. ISOS placed notices on the Certified Provider webpage stating there is no
charge in an attempt to overcome their past. The TMA Program Integrity
Office routinely accuses providers of fraud when in reality all the
provider did was comply with local medical industry standards or not
understand the complex U.S.
medical coding process. TMA openly claims 64% of all Philippine
providers are under prepayment review for fraud. These constant charges
made against local providers causes many to avoid any association with
TRICARE. TMA and ISOS refuse to tell a provider that they are being
certified because a specific TRICARE beneficiary saw them because they
claim it is a violation of patient privacy.
[iii] Beneficiaries have
reported many instances of this happening on a fairly routine basis.
Most often it appears that the ISOS employees become confused as to the
location of a provider and simply give up instead of using some
initiative. One example was a provider who moved his office to another
building down the street. It was likely that a physician with a clinic
near the provider’s old office would have known where he moved.
Secondly the provider was already certified at another location and a
simple phone call to the other location could have resolved the issue.
Instead the provider was classified as not certified. In another
example the employees went to an annex of a large hospital where they
couldn’t find the doctor’s offices. In actuality the two doctor’s
offices were located in the main hospital facility a block away but
they didn’t bother to follow-up and simply declared both doctors as not
certified. In all instances the claims were denied due to the
beneficiary seeing providers who were not certified but no explanation
[iv] We have suggested to
TMA on a number of occasions that they should take the initiative and
reopen these claims and continue to process them. The response was that
it would cost additional money to correct the claims declined in error
which they were not willing to commit.
[v] Mail the letter to
International SOS, 2802D-2803A West
Tower, Philippine Stock
Exchange Center, Exchange
Road, Ortigas Center,
Pasig City Metro Manila, Philippines. Phone
+63 2 687 0999
[vi] The claim number
indicates the date a claim was officially entered into the system and
claims processing started. The claim number is made up of two parts.
Both parts consist of seven numbers and the first part represents the
year and Julian date when processing started. In this example, 2010333
0001769 the first four numbers represent the year, in this case 2010.
The next three numbers represent the Julian date, in this case day 333rd
day of the year. Convert this date to a normal date, 29 November 2010,
and compare it to the “Date of Notice” on the EOB.
[vii] WPS normally transmits
requests for certification on an individual basis and ISOS responds
with a list of providers certified or not certified once a week.
Therefore ISOS would first check their files and immediately report a
denial based on a previously declined certification request which would
cause the response to be received in less than two weeks.
[viii] There is a specific
fax number for faxing correspondence: (608)301-2250
[ix] If the physician fee
is embedded in a global bill from the hospital and not broken out,
unless you identify this in your narrative and allocate a portion of
the global bill to the staff physician’s fee it is likely WPS will find
the billed amount as over the CMAC and disallow a portion of the claim.
The amount allocated will depend on the procedure and the CMAC rates
for the specific professional fees for that procedure.